2.0 Analysis 2.1 Introduction Although the failure of the No. 1 main tire resulted in decreased aircraft braking effectiveness and a slight increase in the landing distance required, it was primarily the delayed touchdown that resulted in insufficient runway remaining to stop the aircraft. Therefore, the analysis will concentrate on the approach profile and the captain's decision to continue with the landing. 2.2 Approach Information When ROY4529 departed Halifax, the St. John's weather was a 200-foot ceiling and 1/4 mile visibility. Since the company operates under a pilot self-dispatch system and the minimum requirement to conduct an approach is 1/4 mile visibility, the captain's decision to depart was procedurally correct. The 1410 ATIS reported that the visibility had increased to one mile. However, the weather updates after the 1410 ATIS report and the RVR for runway 11 reported by the tower before the aircraft reached DH indicated that the visibility at St. John's was deteriorating. The captain disconnected the autopilot and continued with a manual approach before descending below 2,000 feet asl. With the deteriorating weather conditions and the gusty cross-wind conditions on final approach, the captain would have been less heavily tasked if he had maintained the aircraft on autopilot and completed a coupled instrument approach. This would have allowed him to spend more time monitoring the approach and preparing for the transition to visual for landing. When the captain saw the runway and realized that the aircraft was left of the runway centre line, he corrected to the right. This right turn, combined with the left cross-wind, caused the aircraft to drift to the right of the runway centre line. It is likely that when the captain saw the runway, he automatically turned towards it and corrected too far to the right. This, in effect, removed the crab that was maintained for the cross-wind conditions and resulted in the aircraft drifting from the desired track. At the estimated time of threshold crossing, the aircraft was descending through an approximate altitude of 110 feet agl. This indicates that the aircraft had deviated above the glide slope at some point during the approach. Nine seconds before threshold crossing, the captain reduced the rate of descent of the aircraft; this is likely when the aircraft went above the glide slope. 2.3 New Captain Limits The captain continued with the approach to runway 11, even though the reported St. John's weather was below the company weather limits for new captains. The captain never consciously considered the higher minimums for new captains in his decision to continue the approach. During his simulator training, approaches were flown referencing CAP limits and not the higher limits for new captains. It is probable that on the incident flight, the captain referenced the CAP limits. Training conducted in a simulator is the best opportunity for a company to check a pilot's proficiency, including flying the aircraft down to CAP minimum approach limits. These are the minimum limits that the pilot will be expected to perform to on a normal basis. Had the captain observed the higher limits during the approach to runway 11, he would have begun a missed approach procedure when he reached those limits. His options then would have been flying a second approach and, if unable to land, flying to his alternate airport. The intent of the higher limits for new captains is to provide a safety margin until they have acquired experience as a captain on the aircraft type. 2.4 Runway Lighting The aircraft approached St. John's from the west; therefore, runway 11 provided a straight-in approach to the airport. Since the prevailing winds, although gusty, were approximately 90 degrees to the runway, a landing on runway 29 would not have appeared more favourable and would have taken more time. The lighting on runway 29 includes touchdown zone lighting, and the last 3,000 feet of runway centre-line lighting is marked with a change from white to red lighting. If the crew had used runway 29, the additional lighting might have aided the crew in better identifying the touchdown zone and the runway remaining. 2.5 Approach Airspeed The captain and first officer set their airspeed bugs prior to the descent to St. John's. The approach was flown at a speed 11 knots faster than the bug speed of 154 knots, and the aircraft crossed the threshold at a speed 18 knots faster than the threshold crossing speed of 147 knots. Approaches flown at speeds above bug speed can result in the aircraft floating and a delayed touchdown. The captain did not start reducing engine approach power until the aircraft's deviation from the centre line was corrected and the aircraft was 2,500 feet past the threshold. The pilot reported that the aircraft floated during the flare. The wind was effectively 90 degrees to the runway, and the absence of a headwind component would have caused the aircraft to float further than anticipated. Had the pilot been more firm in landing the aircraft, even with the excessive threshold crossing speed, the floating distance could have been reduced. 2.6 The Landing The aircraft was to the right of the centre line as it crossed the threshold, and a 12-degree left bank was required before the aircraft was positioned to continue the landing flare. This manoeuvre, coupled with a speed higher than the bug speed and a higher-than-published threshold crossing height, consumed runway and delayed the flare. The captain believed that there was sufficient runway remaining and continued with the landing. However, because visibility was poor and there was no category 2 runway lighting to rely on, the flight crew members were unaware of the runway distance that had already been overflown. They were also unaware of the runway remaining when the aircraft touched down. The absence of a headwind, the aircraft's extra height over the threshold and excessive airspeed, and the lack of firm landing techniques contributed to a long float and a delayed touchdown. The result was insufficient runway remaining to stop the aircraft. The runway end came into sight only after the thrust reversers were deployed; the crew correctly assessed that it was impractical and unsafe to attempt a go-around. 2.7 Cabin Attendant Response The IFD was prepared for an emergency evacuation signal from the flight crew and had briefed the adjacent flight attendant prior to getting up from his jump seat. When the signal was not given, he correctly responded by approaching the cockpit for instructions. Although all of the other cabin attendants were inexperienced, their recent training prepared them to focus on their crew duties. 3.0 Conclusions 3.1 Findings The flight crew was certified, trained, and qualified for the flight in accordance with existing regulations. The incident flight was the captain's first flight as pilot-in-command since his upgrade to a Boeing 727 captain, two days earlier. The captain flew the ILS approach without the assistance of the autopilot. The aircraft target speed flown throughout the approach was 11 knots above the bug speed. The aircraft crossed the threshold at a speed 18 knots above the required threshold crossing speed. When the crew saw the runway, the aircraft was slightly left of the runway and above the glide slope. While the captain was manoeuvring the aircraft to get back on the runway centre line, the touchdown was delayed. The flight crew was not aware of the aircraft location in relation to the end of the runway at touchdown because of the limited visibility. The captain was not firm with the touchdown, which resulted in an excessively long float; the touchdown occurred 5,100 feet after threshold crossing. The No. 1 main tire blew during the landing because of non-rotation. The brake/anti-skid and hydraulic systems were found to be serviceable after the incident. The reason for the No. 1 wheel lock-up could not be determined. Because the captain was new, his minimum approach limits were to be higher than the CAP limits by 100 feet for the ceiling and 1/2 mile for the visibility. At DH, the captain called landing when the reported meteorological conditions for a landing on runway 11 were below the limits for a new captain. The CAP limits were referenced during company flight crew simulator training; the higher limits for a new captain were not referenced. 3.2 Causes The crew continued with the landing when there was insufficient runway remaining to stop on the runway surface. Contributing to the overrun were ineffective landing technique, excessive altitude and airspeed over the runway threshold, and the use of inappropriate approach limits for a new captain. 4.0 Safety Action 4.1 Action Taken 4.1.1 Operator Action Subsequent to the occurrence, the operator indicated the following: crew experience is now reviewed prior to pairing crews; weather limits for new captains are now stressed during recurrent training and will be enforced; crew resource management (CRM) training is now integrated into recurrent training; coupled approaches in low visibility are now included in simulator training; standard operating procedures (SOPs) have been amended to enhance consideration of usable runway, type of approach, lighting, and visual aids; ground school lectures and line indoctrination now place greater emphasis on landing performance field limits, landing speeds, and wind additives; and combined cockpit and cabin crew training will be conducted once a year. 4.1.2 Crew Resource Management The flight crew of the accident aircraft did not make use of the autopilot during the approach, nor did they use runway 29, which had better lighting. Use of either of these resources might have prevented the runway overrun. The effective use of all available resources, including equipment, is an integral part of proper CRM. The flight crew had not received training in CRM, nor were they required to. The new Canadian Aviation Regulations, to be promulgated in 1996, will require all airline flight crews to take such training.